Wednesday, July 21, 2010

Continuity of Care

In psychiatry teaching, lots of attention is paid to using our emotions as "data" for understanding our patients. In ethics teaching, lots of attention is paid to developing the logical rationale for our conclusions. As a psychiatrist who teaches ethics I find that I do both.

Dr. Feld describes how she found a lump in her breast, tried to deny it was there, visited her gynecologist, had a mammogram, an ultrasound, and then a biopsy. Here are the paragraphs that got me teared up:

For the next 48 hours, as I wait for her call, I feel suspended, hanging from a strap cinched too tightly around my chest. Waiting to hear just how bad the news is. Waiting to hear when I will move forward and to what unfamiliar places I will go.

When she does call, much of the conversation is a blur, but I remember three things she tells me with immeasurable kindness: that the lump is malignant, that she will take care of me, and that she and I will know each other until one of us dies.

I am transformed — from a ridiculously healthy person to one with a life-threatening diagnosis, from someone who does not go to doctors to someone who does, from a doctor to a patient. My life path has veered off a sunny road into a dark and treacherous jungle. I feel dazed and disoriented from the wrenching metamorphosis, but so lucky to have this woman walking beside me holding a compass.

I asked myself the question I ask my students - "put your tears into words - what do they tell you?"

I haven't yet had the kind of health experience Dr. Feld describes so movingly. But even though psychiatrists aren't dealing with cancer, in my practice I've so far had the privilige knowing my patients "until one of us dies." The longest time that has involved is forty-four years.

In my third year of psychiatry residency we spent six months in a "walk-in clinic," where patients could come without an appointment to be seen for an initial visit. We were told "the person you see is your patient until the two of you agree on another plan." I'm still in contact with people I know from walk-in clinic days. (Two years ago I wrote a post about one of them.)

Judging from my own experience, and what I've heard from innumerable colleagues, the experience Dr. Feld writes about with such sensitivity is as meaningful for the doctor as it is for the patient. The patient may have the illness, but we share the fact of vulnerability and mortality. What a privilige it is (using Dr. Feld's words) to walk alongside of fellow human beings, responsible for carrying a shared compass.

The tears were for gratitude for the privilige of being allowed to care for patients, and hope for receiving what I've been allowed to offer when my own time comes.